Tuesday, June 05, 2007

Neck manipulation and strokes?

A few years ago, a very good friend of mine suffered a stroke from a dissected carotid artery. Once they had an image of her neck and saw the damaged blood vessel, one of the first questions the attending neurologist asked was, "Has she been to a chiropractor recently?" In fact, every single neurologist who saw her in subsequent weeks asked the same question.

These questions reflect a belief among some doctors that neck manipulation by chiropractors can cause damage to the arteries in the neck, leading to the creation of clots that can then enter the brain and cause an ischemic stroke. Here is an example of an article on the subject.

As you know, I am not a doctor, and I do not pretend to be an expert on such things. I also know that chiropractors do miracles for many people and alleviate lots of pain. So this is not a diatribe against that profession. Far from it.

Obviously, this is an area in which clinical trials and randomized studies are difficult. But, I now always warn my friends to be alert to this potential danger and seek gentle approaches to neck pain.

12 comments:

Anonymous said...

why are you awake at 5:53

Anonymous said...

Why Paul is awake at 5:53 AM?. That is one of the reason he is the CEO of biggest hospital. High achievers work hard...and get up very early. They cant wait to get to work.

Anonymous said...

As someone who works in Neurology I have heard this mentioned many times. Most Neurologists warn patients to stay away from chiropractors.

I had my neck manipulated once a few years ago and I felt dizzy for a few days after.

A neurologist said...

There is in fact a well developed literature on carotid and vertebral artery dissections caused by neck manipulations by chiropracters. (Carotid artery dissection is more common overall, but chiropractic manipulation has a much stronger relationship with vertebral artery dissection, so most of the literature is on that.) We see a few such cases (1-3) every year. That is why we ask about it, and why we tell patients with neck problems that they should not have chiropractic manipulation done.

If you go to PubMed (http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed) and search for “dissection chiropractic” you will find 82 papers on this topic, about 20 in the last few years.

The one by Reuter et al. (Vertebral artery dissections after chiropractic neck manipulation in Germany over three years. J Neurol. 2006 Jun;253(6):724-30.), is particularly good, because they monitored an entire country (Germany) and found about one case per major medical center per year. That is more significant than it may sound, as chiropractic is an American invention, and much more commonly practiced here.

The study by Smith et al. (Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology. 2003 May 13;60(9):1424-8.) is also useful, because it assays frequency of chiropractic manipulation among people with vertebral artery dissection in the US, and finds it is 5 times as common compared to control subjects who did not have a vertebral dissection. This would suggest that chiropractic manipulation may increase the risk of vertebral dissection by about 5 fold. Because the risk of vetebral dissection from all causes is low, the risk following chiropractic manipulation is still fairly low. But it is a very real risk, and if it happens to you, you have a 100% chance of a bad outcome.

Chiropractors predictably do not like this concept. They claim that they rarely if ever see this complication, and to be fair, from their point of view it is probably true. They may perform thousands of manipulations per year, and it is unlikely that a patient who suffers a dissection will come back to the chiropractor (they go to an Emergency Department when they suddenly cannot move their left side, not to the chiropractor), and most may not even report the problem to them, so they rarely if ever see this result. There is a small literature on this subject from the chiropractic perspective (some of the papers in PubMed are from the Journal of Manipulative Physiology and Therapy, a chiropractic journal). If you read them, you will see that they do not contain comparable data or statistics on frequency of this complication.

Anonymous said...

Can someone give a brief description of a 'manipulation' ?

Do they jerk you around to create cracking noises similar to cracking nuckles?

Paul Levy said...

David, in response to your note, please read http://runningahospital.blogspot.com/2007/03/play-ball.html for an explanation of our relatinship with the Red Sox.

Toni Brayer MD said...

Manipulation is a term used in chiropractic that can range from gentle pressure to wack 'em crack 'em. In medicine we use the term manipulation to mean any maneuver that moves tissue around.
I went to a chiropractor once with severe neck stiffness and he was so rough I cried with pain and I had a severe headache for days. I could definitely see the potential for severe damage.

Dave said...

thanks - dave

Anonymous said...

I think Eddie Izzard in 'Dress To Kill' has the best, most accurate, and most hilarious take on chiroquackters.

If y'all ain't seen it, y'all should.

YouTube anyone?

Bwana said...

Okay, okay, I'll get Al Gore and Michael Moore on this right away.

Hi Paul. As you know, I was away for a bit and just catching up on your blog.

This chiropractor stuff is scary because there is no follow up, as far as I can tell, regarding cause and effect when neck injuries occur.

Many years ago, in my twenties, I was at a chiropractor's office - he was a friend of a friend and he described some of the stuff they did. Right then, I decided it was, from my point view, goofytechnics and I've never been to a chiropractor. Never will.

cheerz...Bwana

Great gadfly said...

And then there are those who are fortunate enough to find the truly gifted healer/dc or do. Without the chiropractor whom I see as needed I would have lost the use of my left arm twelve years ago, would not be mobile after the damage I have sustained to eleven disc, etc. As in all trades there are the good, the bad and the brutal.

In Roman times and earlier manipulation and tractioning were about the only treatments, other than unspeakably painful surgery, for the ailments of the laborer, the soldier and the gladiator. Perhaps we should teach Gallen in medical schools. My first experience with chiropractic was at the suggestion of my neuro-surgeon...who never cut me because the chiropractor did the trick. When I suffered a broken neck playing rugby forty-two years ago the only treatment was traction and rest...then back to the gymn and eventually to the game. Without occasional manipulation I would be a basket case today.

kathy said...

I am a chiropractor and I can't find the info about what kind of manipulation is associaated with stroke problems. Is it head exteension and rotation? Manipulation is such a broad term. I get adjusted regularly, but I have had adjustments from one or two chiros that make my ears ring and I dont go back to the rough ones. Does any onehave any specifics on more dangerous adjustment types ?